Registration Form  Journey to the Source
INSTRUCTIONS: Please fill out this form completely (both sides, print clearly, sign on the back) and return* with your full payment.
CHECK ONE:
Mr.
 Miss
 Mrs.
FULL NAME AS IT APPEARS ON PASSPORT
COMPLETE STREET ADDRESS
CITY
APARTMENT NUMBER
STATE/PROVINCE
ZIP CODE
TELEPHONE DAYTIME
TELEPHONE EVENINGS
FAX NUMBER
E-MAIL ADDRESS
DATE OF BIRTH (AS PER PASSPORT)
NATIONALITY (AS PER PASSPORT)
PASSPORT #
DATE OF ISSUE
CITY OF ISSUE
EXPIRATION DATE
VISA #
VISA EXPIRE DATE
EMERGENCY CONTACT INFORMATION:
FULL NAME
COMPLETE STREET ADDRESS
CITY
APARTMENT NUMBER
STATE/PROVINCE
ZIP CODE
TELEPHONE DAYTIME
TELEPHONE EVENINGS
FAX NUMBER
E-MAIL ADDRESS
RESPONSIBILITY:
Chakra Institute, Inc., acts only as an agent for the suppliers and contractors
providing transportation and/or all other related travel services and assumes no responsibility howsoever
caused for personal injury, personal or property loss or damage in connection with any service resulting
directly or indirectly from Acts of God, detention, annoyance, delays and expenses arising from strikes,
thefts, failure of any means of conveyance to arrive or depart as scheduled, civil disturbance, government
regulations, discrepancies or changes in transit or hotel services over which it has no control. Reasonable
changes in itinerary may be made where necessary or deemed advisable for the comfort and well being of
passengers. All prices are based on recent tariffs and exchange rates and are subject to change with or
without notice, depending on the prevailing tariffs and / or any changes in foreign exchange rates.
Please go to reverse side:
CHAKRA INSTITUTE, INC. TRAVEL DISCLAIMER
Chakra Institute, Inc. does hereby collectively include InnerTuning®, InnerTuning Systems, Inc., Chakra
Institute, Inc., Chakra Institute, Shyam Bhatnagar, and all shareholders, officers, directors, employees,
staff, and/or agents of any of these entities. As a part of certain of the Chakra Institute workshops,
purifications and/or events, including “Journey to the Source” (“Event”), it is expressly understood that
Chakra Institute is only acting as a facilitator for various suppliers and contractors who will provide
various transportation services and/or other related services for the Event. Chakra Institute assumes no
responsibility and shall have no liability whatsoever for any personal injury or property loss by any
means, or for any damages of any kind, in connection with any services provided, which damage or injury
results directly or indirectly from any cause whatsoever, including but not limited to, negligence, acts of
god, detention, annoyance, delays and expenses arising from strikes, thefts, failure of any means of
conveyance to arrive or depart as scheduled, civil disturbances, government regulations, discrepancies or
changes in transit or hotel services over whether or not it has control over same. Changes in the itinerary
may be made, when necessary or advisable for the comfort and well-being of the participants. All prices
are based upon recent tariffs and exchange rates and are subject to change without notice.
Travel services may include, but are not limited to, air planes and other modes of air transportation,
trains, buses, automobiles, auto rickshaws, bicycle rickshaws, and live animals (including elephants.)
By accepting and participating in the use of any of these modes of transportation during the Event, you
expressly waive all claims of liability and/or responsibility against Chakra Institute. You participate at
your own risk, as Chakra Institute makes no representations whatsoever concerning these matters. Chakra
Institute assists in providing various travel services to its participants, but is not responsible in the event
the supplier, for any reason, fails to honor the booking. It is the participants’ responsibility to be aware of
the terms and conditions of travel arrangements purchased. The entire risk arising out of any provided
travel services shall be with the participant. Chakra Institute shall be under no liability to you or any third
party whatsoever by reason of any loss or damage, including direct, consequential, incidental, indirect,
special or other damages (including, without limitation loss of profits, goodwill, use, data or other
pecuniary and/or intangible losses) resulting from your participation with the Event.
To the fullest extent permissible by law, Chakra Institute disclaims all warranties, express or implied, and
shall not be liable for any direct, indirect, incidental, special, or consequential damages (including but not
limited to lost profits, and damages that result from accidents, inconvenience, delay, or loss of use of the
services provided) arising out of any transportation or other services in connection with the Event.
Should any portion of the foregoing limitation on liability be deemed unenforceable, in no event shall
Chakra Institute’s aggregate cumulative liability in any circumstance arising out of or relating to the
Event exceed $108. You agree to reimburse and hold harmless Chakra Institute against any claims which
you have or may have, which arise directly or indirectly from this Event or from any related activity or
service provided, including the transportation services set forth herein.
The Client understands and agrees to the above:
(Print Participant name above)
Client signature: ______________________________________________
Date: ________________________
IMPORTANT NOTE: The government of India requires a current visa to enter the country. Consult their local office for details.
*TO COMPLETE REGISTRATION: Send this form with registration payment in full in $ U.S. payable to:
Chakra Institute, Inc., P.O. Box 34, New Hope, PA, 18938, USA.